Temporomandibular Joint Disorders Following a Motor Vehicle Accident – A Scoping Review for Canadian Dental Professionals

Introduction

Motor vehicle accidents (MVAs), defined as collisions involving motor vehicles with other vehicles, pedestrians, animals or stationary objects, are known to cause a variety of injuries, including whiplash-associated disorders (WADs). Whiplash is characterized by a sudden, forceful back-and-forth movement of the neck, which is frequently associated with the onset of symptoms of temporomandibular disorder (TMD).^1,2 The prevalence of TMD after an MVA is reported to be significantly higher than that in the general population not involved in MVAs, with a notable incidence of TMD in those reporting a history of whiplash.^3,4 In 2022, Canada saw an increase in the number of fatalities, serious injuries and total injuries from MVAs compared with the previous year. Despite this, there has been a long-term decline in the number of MVAs resulting in a single injury but no fatalities: from 150 493 in 2003 to 89 787 in 2022. The most frequent occurrences of serious injuries and fatalities were among people aged 25–34 years.^1,5

The interrelation between TMDs and MVAs remains a subject of both medical and legal debate, compounded by the inherent variability in symptom presentation and the multifactorial nature of treatment approaches. This complexity is further amplified by significant legal implications, particularly concerning the future care costs and litigation in some Canadian provinces.

TMD encompasses a spectrum of over 30 clinical conditions affecting the temporomandibular joint (TMJ) and associated musculature. These conditions are generally classified into 3 primary categories: joint disorders, masticatory muscle disorders and TMD-related headaches.⁶ The pathophysiology of MVA-related TMD may involve both direct mechanical trauma to the TMJ and indirect effects, such as changes in the central nervous system, with psychological stress playing a contributory role.^2,7

In addition to the indirect trauma associated with whiplash during MVAs, patients may also experience direct trauma from various internal and external sources, such as airbags, seatbelts and other components of the vehicle, as well as external objects, such as poles and roads.⁸ This scoping review seeks to consolidate and evaluate the existing literature on the nexus of TMD and MVAs concerning diagnosis, symptom onset, radiographic presentation, treatment modalities, prognostic outcomes and litigation, thereby informing the broader medical, dental and legal communities on optimal management strategies for this patient group.

Methods

Our study population included all patients aged ≥18 years, who had been involved in an MVA. All settings of MVA accidents and patient complaints were included, i.e., patients seen in all clinical contexts (medical and dental settings). There was no restriction on geographic location.

The databases PubMed, EMBASE, Web of Science, Cochrane and Scopus were queried. Types of studies included were experimental, observation and reviews. There was no limit on articles by date, but only articles published in English were used. The review was registered with PROSPERO (ID CRD42023400003).

Terms used in the search strategy were: (motor* OR vehicle* OR automobile* OR car OR cars OR truck* OR traffic) adj3 (accident* OR collision* OR crash*) AND temporomandibular OR temporo mandibular

On 28 May 2023, we identified 400 articles from Scopus, 285 from MEDLINE, 145 from PubMed, 505 from Embase, 322 from Web of Science and 7 from Cochrane. All articles were uploaded to Covidence (Melbourne, Australia) for organization and screening. After removing duplicates, 697 articles were screened for relevance using titles and abstracts independently by NB and KP. RF resolved any conflicts. A total of 141 full-text articles were then independently reviewed by authors NB and KP, and 37 articles were included (Figure 1).

Results

The 37 articles analyzed in this review were categorized according to their primary focus among the search objectives, although several articles addressed more than 1 of the 6 areas of interest. Table 1 illustrates the distribution of articles across these outcomes: 15 articles were concerned with diagnosis,^4,9–22 6 with symptom onset,^23–28 13 with treatment options,^{15,16,18,24–26,29–35} 10 with prognosis,^{13,24–26,29,36–40} 6 with radiographic features^40–45 and 5 with litigation factors.^{21,25,31,38,43} Some articles contributed to multiple outcomes. Relevant findings from each article were systematically highlighted and are detailed in Tables 2–7.

In the diagnosis of TMD patients after an MVA (Table 2),^4,9–22 evidence suggests no unifying symptomatology. In multiple studies, people with recent whiplash trauma reported a higher prevalence of jaw pain, higher pain intensity and greater symptoms compared to patients without a history of whiplash trauma. ^7,11,14 Common diagnoses included limited mouth opening and disc displacement.¹⁴ However, it was also suggested that in patients with TMD and whiplash injury, higher pain prevalence might be a result of psychological distress.

Regarding the onset of TMD symptoms following an MVA (Table 3), 1 paper reports immediate symptoms after a whiplash injury, including a “click” sound and limited mouth opening.²³ Nonetheless, acute symptoms of whiplash trauma are uncommon and little to no pain is usually perceived immediately after the injury.^24,28 Corsalini et al.²⁴ suggest that symptomatology increases over the few days following injury, while Al-Ani²³ suggests it may take up to 3 or 4 weeks for symptoms to develop; others suggest that period may be up to a year.^27,28

Treatment options for TMDs following an MVA (Table 4) primarily involve conservative strategies, such as medications, physiotherapy and occlusal appliance therapy. Adopting a comprehensive full-body treatment approach is recommended, especially under the supervision of clinicians who specialize in these conditions, including pain physicians or dental specialists such as oral medicine specialists and oral surgeons. Although surgery is generally not the first course of action and has been minimally explored in post-MVA scenarios, minimally invasive procedures, like arthrocentesis and arthroscopy, may be considered for cases presenting with structural damage or jaw locking.

Multiple factors could impact the prognosis of TMD patients following an MVA (Table 5). Gender, age, initial severity, pre-existing conditions and type of collision were a few of the factors assessed. Also examined was which factors could impact certain types of injury, i.e., limited mouth opening vs. jaw tenderness. The development of acute TMD issues into chronic TMD issues was also examined.^26,29

Radiographic features of TMD that are evident following an MVA include disc displacement, with and without reduction, and MRI was used in many studies (Table 6). The development of osteoarthritis does not appear to be related to an MVA.

We examined whether ongoing litigation impacted TMD signs and symptoms and whether there were any objective differences between non-litigating and litigating patients (Table 7). The relevance of these findings to Canadian clinicians may change depending on whether their province has “no-fault insurance.” In 1 study, significantly more symptomatic complaints were noted by litigating patients.²⁵ However, the opposite was seen in a Lithuanian study.²¹ Grushka et al.⁴³ reported no difference in range of opening; however, TMJ capsulitis was significantly more common in the litigating group vs. the non-ligating group.⁴³ Disc displacement with reduction was greater in litigating patients. In 1 article, no apparent difference in symptoms was found between those who had settled claims and those who had not³¹; however, those in litigation were in treatment longer, requested more treatment and reported more pain.

Discussion

Existing research shows mixed findings related to TMD diagnosis following an MVA. In diagnosing TMD, patient questionnaires and self-reported pain levels need to be considered in the context of a widespread pain complaint. Masticatory muscle pain and headaches are common after whiplash.⁴ Crepitus is typically not associated with whiplash trauma, although disc displacement and adhesions are commonly seen.⁹ Other studies have rebutted this finding.¹⁰ An unknown, yet critically important factor, is whether TMJ disc displacement is a result of the trauma or simply a pre-existing condition.²⁰ This is known to influence medical/legal proceedings. Osteoarthritis has not been found more often following MVAs.¹⁹ However, findings suggestive of disc displacement (clicking and deviation on opening) and limited mouth opening appear to be common features, with TMJ pain found commonly.¹⁶ A significant factor contributing to chronic pain is psychological distress, which may present secondary to an MVA.²² A thorough evaluation must include muscle palpation, range of motion measurement, jaw function assessment and psychological screening. General dentists encountering patients with TMD stemming from MVAs should consider referring them to specialists in this field for accurate diagnosis. A thorough TMJ evaluation is crucial to establish a dependable baseline of TMJ health. Without this foundational assessment, it becomes challenging to evaluate damage or the worsening of pre-existing conditions, retrospectively. In addition, without a clear baseline, monitoring the degree of improvement can be problematic. This is especially vital in litigation cases, where precise diagnostic benchmarks are essential.

When considering the onset of TMD after an MVA, it is essential to include a wide timeframe. Typically, acute symptoms are minimal and may be masked by the severity of other problems, or they may gradually increase with edema diffusion in soft tissues.²³ Delayed onset may range from a few weeks after the injury to a year; delayed onset occurs in a third of people exposed to whiplash trauma. This wide range of symptoms demands careful examination and further study to narrow it down. A common cause of delayed onset is that more serious cervical symptoms can mask the TMD concerns and can take several weeks to resolve.²³ TMD symptoms following MVAs tend to present within a few months. However, dental practitioners should monitor patients closely for up to a year after whiplash trauma occurs, as delayed onset and recognition are more common than acute onset.

Forms of treatment for TMD include occlusal appliances, occlusal adjustments, surgeries, medications (analgesics, muscle relaxants, anti-inflammatories, etc.), physiotherapy and psychological treatments. Establishing a good baseline and monitoring changes are paramount to successful treatment. MVA-related TMD patients tend to receive more types of treatments and medications and have poorer outcomes compared to patients without a history of MVA. Most articles tend to support the notion that initial treatment should be conservative (medications, physiotherapy, psychological counseling, occlusal appliance therapy) before moving on to surgery, if needed. The success of muscle relaxants and analgesics is limited.²⁶ In acute situations, prednisone can be considered. Intramuscular lidocaine (trigger point injections) is superior to no treatment for chronic symptoms. Botulin type-A toxin in small trials has been shown to provide some general relief of symptoms and increased range of motion in patients with whiplash.⁴⁶ The success of jaw exercises in reducing symptoms is inconsistent across studies, with some showing positive benefits,³⁰ but others not.³⁴ Occlusal appliances have been shown to reduce TMD²⁹ and also to be successful when used in conjunction with other treatments, such as physiotherapy and pharmacotherapy.²⁴ The reviewed studies exhibited significant variation in the types of occlusal appliances used, their specific indications and the subsequent treatments administered. Consequently, it is not possible to offer specific recommendations.

There is no evidence of the success of treatments proposing structural changes (occlusal treatment or surgery) in post-MVA patients.²⁹ Krogstad has suggested that the best course of treatment is a holistic, biopsychosocial approach.¹⁵ Referral to chronic multidisciplinary pain clinics that include a psychologist is ideal; however, wait times are often long and treatment is difficult to access. Minimally invasive surgical procedures, such as arthrocentesis have been shown to be effective for pain relief and reestablishing normal opening; however, this has not been studied thoroughly in the context of MVAs.⁴⁷ Treatment approaches for TMD related to whiplash vary widely, and no standardized method has been established. A general dentist should ensure that a precise diagnosis is made before beginning conservative treatment. If the diagnosis remains unclear, a referral is recommended. If there is no improvement after a short period of conservative treatment or if legal considerations are critical, collaboration with appropriate specialists is recommended. Although early intervention is likely to be advantageous, there is currently no evidence explicitly supporting this assertion.

It has been suggested by multiple articles that women, in general, are at higher risk than men for more clinical symptoms.^36,39 It has also been shown that age can be a significant factor in jaw tenderness, maximum opening and symptom chronicity, with older patients exhibiting poorer prognoses. ³⁸ Other factors that have been shown to impact chronicity are severity and pre-existing jaw dysfunction/disorder.²⁴ Rear and front collisions and insurance claims have all been shown to be significant prognostic factors.²⁹ The severity of vehicle damage and age affect final jaw muscle tenderness, while only age and gender affect maximum opening.³⁸ From this, we can see that multiple factors influence various TMD symptoms. Regarding the progression of TMD from an acute to a chronic state, non-painful clicking will develop in 70% of patients,²⁹ and approximately 15–40% of patients with acute symptoms develop chronic symptoms.²⁶ According to another article,³⁹ 68% of patients with jaw pain report it again at the 2-year follow up. It is common for pain to persist for years, and often symptoms can worsen over time. The reason for this needs to be further elucidated.

In examining MRI findings for patients with TMD following an MVA, most studies cannot correlate TMJ findings with the MVA. However, Lee et al.⁴⁴ report that TMD patients with whiplash are more likely to have disc displacement without reduction and disc deformity. Grushka et al.⁴³ found a high prevalence of disc displacement, both with and without reduction, in TMD patients post-MVA. However, compared to non-trauma TMD patients, post-MVA patients demonstrated a significantly lower frequency of disc displacement based on MRI findings, suggesting fewer anatomical changes in the temporomandibular joint.

Similarly, Salé and Isberg²⁷ reported that their imaging findings in patients after whiplash trauma were the same as those with no previous trauma and that TMJ pain was not associated with disc displacement. Clinical symptoms of TMD could not be correlated with MRI findings, and there was no difference between patients with whiplash TMJ and non-whiplash TMJ with disc displacement without reduction and condylar degeneration.⁴⁴ A complex issue is that osseous changes occur naturally with aging and might be mistakenly attributed to the MVA.⁴¹ The reviewed studies did not include panoramic radiographs. Furthermore, the correlation between MRI and CT findings and symptoms of TMD following MVAs remains ambiguous. Nonetheless, clinical evaluations should guide the decision-making process concerning the use of imaging techniques.

TMJ capsulitis and imaging that shows disc displacement without reduction are significantly more common among litigating patients compared with non-litigating groups; other signs, symptoms and radiographic features show no significant differences. However, there is a noticeable tendency for litigating patients to remain in treatment longer and report higher levels of pain. This may be attributed to the pursuit of financial compensation during litigation or more severe symptoms prompting the need for legal representation. In Lithuania,²¹ no increased severity of symptoms was reported for litigating patients, and compensation tended to be statistically lower. Why litigating patients may require more prolonged treatment remains unclear, and additional research is warranted. According to Alberta regulations,⁴⁸ TMJ injuries involving bone or teeth damage or disc displacement are not classified under minor injury regulation, which has implications for litigation and the costs of future care. In litigation cases, a dental specialist is recommended to oversee the management of care to ensure accurate diagnosis and effective monitoring, including evaluating potential malingering.

This scoping review has several strengths, including a comprehensive search strategy encompassing multiple databases and a rigorous screening process to ensure the proper selection of relevant articles. The adherence to PRISMA-ScR guidelines further substantiates the methodological rigour of this review. This has allowed for a thorough examination of the multifaceted relation between TMD and MVAs. However, this scoping review also has limitations. The primary constraint is the heterogeneity of the studies included, which vary in terms of methods, sample sizes and outcomes measured. This diversity makes it challenging to draw definitive conclusions and limits the generalizability of the findings. In addition, longitudinal limits of studies in the included articles restrict our understanding of the long-term outcomes of TMD post-MVA.

Given these limitations, several areas of future research are recommended to enhance our understanding of TMDs post-MVAs. First, well-designed, longitudinal studies are needed to explore the progression of TMD from acute symptoms to chronic conditions. Such studies would help clarify the timelines of symptom development and resolution and identify early predictors of chronicity. This information could greatly improve both prognosis and intervention strategies.

Second, there is a need for standardized diagnostic criteria and outcome measures in studies related to TMD post-MVA. The current heterogeneity complicates comparisons across studies and limits the ability to draw conclusions. Consistent use of diagnostic criteria is suggested. Standardizing these elements would allow for more effective meta-analyses and systematic reviews, providing clearer insights into effective treatments.

Another area for future research is the role of psychological factors in the development and management of TMD following MVAs. Given the impact of psychological stress and trauma in chronic TMD cases, more detailed studies exploring the interplay between psychological conditions and physical symptoms are necessary. In addition, comparative studies that evaluate the efficacy of conservative versus surgical interventions, the role of pharmacological treatments and the benefits of multidisciplinary care approaches are needed. These studies should aim to identify the most effective and patient-centred treatment protocols.

Finally, the role of litigation in shaping the symptoms and outcomes of TMD following MVAs warrants extensive exploration. Future research should endeavour to ascertain whether ongoing litigation directly influences patient symptoms and treatment results or if it simply coincides with more severe instances. Clarifying this relationship is important for shaping the legal and insurance frameworks that impact TMD patients post-accident. These research initiatives would not only fill existing knowledge gaps but also significantly enhance the clinical management and legal aspects of TMD cases related to MVAs, ultimately improving patient outcomes.

Conclusion

This scoping review has explored the multifaceted relation between TMD and MVAs, shedding light on diagnostic challenges, symptom onset variability, treatment efficacy and the impacts of litigation. The evidence underscores the heterogeneous nature of TMD post-MVA, reflecting a complex interplay of physical injuries and psychological factors.

The findings reveal that TMD symptoms can vary widely in their onset and severity and are influenced by factors, such as the nature of the accident and individual patient characteristics. Although conservative treatment approaches, including medication, physiotherapy and occlusal appliance therapy, remain primary, the review highlights the need for a comprehensive treatment strategy incorporating a multidisciplinary team. This approach not only addresses the physical aspects of TMD but also the psychological impacts, which are often significant.

Litigation appears to influence patient experiences and treatment outcomes, with litigating patients often reporting prolonged symptoms and requiring extended treatment periods. This aspect underscores the need for thorough documentation and a nuanced understanding of the legal context in managing TMD post-MVA.

This review has identified several gaps in the current research, particularly the need for longitudinal studies to better understand the progression of TMD from acute to chronic conditions post-accident. In addition, more rigorous investigations into the effectiveness of various treatment modalities in this specific patient population are warranted. Although our understanding of TMD post-MVA has advanced, significant challenges remain and further studies are required.

THE AUTHORS

	Dr. Bhargava is a general practice resident at Dalhousie University, Halifax, Nova Scotia.
	Dr. Perich is a general practice resident at the University of Alberta, Edmonton, Alberta
	Dr. Friesen is an assistant professor at the Mike Petryk School of Dentistry, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta.

Acknowledgments and Funding

Corresponding author: Dean Kolbinson, Dental Clinic, College of Dentistry, University of Saskatchewan, 105 Wiggins Rd, Saskatoon, SK S7N 5E4. Email: dean.kolbinson@usask.ca

NB received funding support from the Oral Medicine and Pathology Undergraduate Studentship.

This article has been peer reviewed.

The authors declare that they have no competing interests.

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